The novel approach resulted from an EU innovation project involving triple helix partners from six different European countries lasting for four years (including 26 months of developing the tools and 19 months of testing them). The three hospital units drew on several approaches to learning, including formal courses in simulation facilities, formal courses in the units, and informal learning. New approaches emerged as the implementation effort unfolded, and others fizzled out. For example, support and repetitive follow-up meetings and training were added along the way, as the trainers were unsure whether the healthcare professionals used the video consultations or not. However, we found that two broad mechanisms, each comprising several sub-mechanisms, were evident in the implementation effort. The education intervention unfolded slightly differently across the three units due to organizational structures, routines, and existing workflows across units and sectors, the characteristics, and the circumstances of the patient groups and next of kin involved, and the experienced level of responsibility among health care professionals. Taking these and other contextual factors into account, we next present the three cases (including the most prominent quotes), followed by a presentation of the key enabling and constraining factors using the two mechanisms as illustrative examples to demonstrate what appeared to make each mechanism more or less likely to produce the outcome.
Neonatal unit
A neonatal unit is a unit for premature infants and sick or vulnerable newborns with special needs. The staff is trained in the care and treatment of premature infants and sick newborns, e.g., helping the babies with breathing and eating. At the end of the hospitalization period, the unit offers ‘early homestay’ to babies that still need help with eating but otherwise are healthy. The parents receive the needed counseling before being discharged to early homestay, and they have consultations with ‘early homestay nurses’ from the unit two times a week. Until COVID-19, these consultations were physical home visits. Due to the COVID-19 pandemic social distancing measures, home visits were no longer possible. Video consultations were therefore proposed to replace these visits. An added value of replacing physical visits with video consultations was the opportunity to save time and resources that could be used in the unit instead. In line with the regional decision to increase the number of video consultations, it was decided that video consultation use should continue even though the social distancing measures were removed. Additionally, the two weekly consultations were reduced to one consultation per week. Before implementing the new workflow, a one-hour preparation meeting was held between the trainers, the unit management, and an IT specialist to plan the training and solve tasks concerning management, workflows, training attendees and their needs, and the value of the training. The training participants were three nurses and one IT specialist from the unit who received two half-day training sessions in the hospitals’ simulation facilities. Additionally, one nurse received informal follow-up training and support the first couple of times she used the video consultations. The training consisted of practical information, hands-on training, troubleshooting, and questions. The hands-on training was based on a case where the trainer took on the role of a parent. The trainer, located in another room, was invited to a video consultation by the nurses. The trainer’s arm was playing the role of the baby, and the nurses asked her to move the camera around so they could detect skin details. During lunch, the trainer sneaked into the training facility and turned off sound and camera or placed black tape on the lens of devices used by the nurses. After lunch, they had to ‘trouble-shoot’ and make their devices work again. The participants expressed that they achieved the digital skills they needed to be able to use the video consultations and appreciated the possibility of support and follow-up training if needed. The trainers added follow-up training 30-60-90 and 180 days after the initial training course as they were unsure whether the video consultations were used or not. According to one of the trainers, “that’s where the missing link is. It’s the transition from the training course to the integration in the unit. I can see that we can do something more there. Develop or adjust what we already do. [...] We have good experience, and it works really well if they first attended our training course, and then we come out there [to the unit]. They [the staff] appreciate that we come to them and help them further. We’re ready to support and answer questions.” Additionally, the unit had a technology-interested nurse formally assigned as a superuser. However, she did not participate in the training. In hindsight, the unit figured out that she probably should have. There was also some resistance to video consultations that occurred when nurses' responsibility toward patients and families and their professional knowledge was contested. As one nurse said, “We feel responsible when we send the patient on early homestay. What if the baby turns yellow [jaundice]? Can we see that through a screen? [...] We cannot see whether they [babies] are dirty or if they [the parents] get them washed up and those kinds of things, so there are a lot of things we cannot see”. On the contrary, the nurses were positively surprised about the video quality during the training sessions. Still, during the hands-on part of the training sessions, they learned that tasks involving bodily and sensuous impressions were not an option. They expressed that they needed to be, e.g., able to feel a hernia or the soft palate with a finger. On the contrary, video consultations were accepted when unit management was responsive to the nurses’ concerns regarding patient safety and soundness. The responsiveness led to customization of the video consultation use; “We have the permission to consider from time to time whether it should be a video consultation or a physical home visit. But it is ok that half of the visits are physical [...]. We think the offer we have now, combining video consultations and physical home visits, is... They [the families] are safe, right?”. The parents found the technology easy to use, which was also important to the nurses. Despite some resistance, video consultations were used 50% of the time, and the nurses expressed the importance of being able to decide themselves, based on their professional knowledge, whether a consultation should be physical or on video. An added value of the video consultations was letting go of guilt due to saved time, as one nurse expressed it: “[...] if I stayed in the ward, I could help my colleges because we often have a bad conscience when the ward is busy. I could have had more time to help them the rest of the day, right?”.
Cardiology unit
The cardiology unit carries out various outpatient examinations, treatments, care, and specialist rehabilitation of patients with cardiovascular diseases. In 2020, the unit joined a project intending to use video consultations in care transitions to respond to regional and patient expectations. The unit management met with the trainers and planned the implementation and training process. The training was carried out as aforementioned, and as the objective of the video consultations was care transitions, the participants consisted of staff from hospitals and the municipality. The training involved case-based exercises, where staff from the hospital and staff from municipalities were paired and should set up video consultations and discuss a case. The IT specialist who attended the training was needed as it was difficult to set up the devices from the municipalities to log in to the system used by the hospital. Only nurses from the hospital could invite participants to participate in video consultations. Internally in the hospital, the nurses had to log in to the system differently from what they were used to. They had to use a unit-based log-in so that they could be replaced by other nurses in the video consultation. Like in the former case, the trainers sneaked into the training facility during lunch and turned off sound and cameras in various ways. The staff then had to troubleshoot and make their devices work again. According to the nurses, they appreciated the training. The training was necessary, but they also said: “I have to admit that I thought it was too smart because it didn’t even work when we did the training.” Further, the nurses said they “couldn’t log on to the system” during training and did not “get an immediate experience of success.” To get the video consultations scaled up after the training, one of the nurses said, "they needed someone to guide them and to be present.” As the unit did not have formal or informal superusers, they appreciated the follow-up and support from the trainers. One of the nurses said: “The follow-up is important because when I’ve been to the training, I thought this could have been done differently. I enjoy the dialogue because the developers do not know the clinic. Sometimes what we are supposed to do is so stupid that I write to them. I experience that they get it, and I really appreciate our support.” Despite some bumps on the road, COVID-19 forced them “to try and see if we could start. If not, we wouldn’t have begun with video”. Some resistance was related to ‘the medical gaze’ and the patient relation. The head nurse said, "It’s not about being resistant because you don’t want to do anything new. It’s about trying to see the person first”. A nurse said that video consultations “can’t reflect empathy [...]. What do a nurse and a physician do? It’s not only objective, you know. It’s what comes out of the mouth […]. It has something to do with... We sit in a consultation and register signals. We do that with all our senses, including sounds and smells. It’s all. It tells me about many things”. Another nurse agreed and said: “Yes, I think we are really dependent on so many parameters. I have an example [...] I had him [a patient] and observed that he was much worse than he thought. Because he told me he was well, and he wasn’t. It turned out at the heart scan that he was in a really bad condition. But he thinks he is well, which is what he tells me. And I haven’t... If it were on video, I wouldn’t know. Because his pulse was way too high. One of the scars was infected. There were so many things that he didn’t react to. He did not tell me, and I had no chance of finding out. Even though I specifically asked these things, he was not capable of identifying or telling me that this was wrong because he did not know himself”. Further, the nurses expressed that through video consultations, “you do not get eye contact in the same way,” “you lose some of the relations” and you cannot “reach out to someone, comfort, or calm down or [...] touch someone”. The nurses expressed that if video consultations should be used with patients, they must make sense and be relevant. Further, the nurses expressed that they need training in personal and communication skills and how to monitor a patient behind a screen to feel safe. The nurses also expressed that they need some positive experiences, a setup for practice, and support on the spot. According to the nurses, it is something else when communicating with peers because “you can easier concentrate on the technical stuff” and “there you don’t have to concentrate on those on the other side of the screen, they understand what you say, compared to patients. Because it’s from peer to peer. That is something else [...]. It makes good sense, and I will make it work when things make sense to me”. A year after the initial training, the unit used video consultations weekly to supervise municipal physical therapists responsible for rehabilitation. A rehabilitation nurse said, “It gives another contact compared to if it’s done by e-mail or telephone because that would be the alternative. So, in this case, it is a good alternative to the physical meeting”. However, the unit nurse stated, "It’s not like it’s time-saving, at least not yet. In fact, quite the opposite. It increases the possibilities you have to handle as an employee. It requires up-to-date knowledge and awareness concerning how to behave when having patients on the phone, how to behave on video, and how to behave in physical consultations.”. Another nurse agrees: “It’s not saving us time yet. It’s an extra task on top of everything else. It might save us some time in the long run or fewer hospital admissions. But the beds will be filled up with other patients anyways”.
Neurology unit
The neurology unit treats patients with neurological conditions caused by trauma, cancer, and infections, as well as chronic and terminal conditions. These conditions often cause complex and long-term problems. As such, the unit collaborates closely with the next of kin and the municipality. Whenever a complex patient is admitted, a ‘multidisciplinary consultation’ is held with the next of kin and relevant municipal actors to start the rehabilitation process. These consultations would typically take place physically in the ward and would often be delayed due to next of kin living far away. In line with the regional decision to strengthen cross-sectoral collaboration with technology, the unit decided to implement video consultations to replace the existing workflow and make rehabilitation more efficient. Before implementation, the trainers had a preparation meeting with the head nurse, a senior consultant neurologist, and the unit manager to plan the implementation and training. Since the unit was quite busy, they did not have the time and resources to send staff off to training in simulation facilities. As such, the training was held by the trainers in the unit and became quite practice-based. The training was carried out as described before, with practical information, case-based hands-on training, troubleshooting, and questions. As the training took place in the unit, municipal actors did not participate in the training. Most of the staff in the unit participated in the training and seemed to have the needed digital skills on the spot. However, three months after the training, the head nurse stated: “I won’t say that it is easy to implement – it's not. The staff... We were many that received training in this, and I heard that when people went from the training, they said, ‘oh, was it that easy?’, ‘that wasn’t so hard,’ and ‘we will figure that out easily.’ And then we got the iPad, and were going to start and then ‘how was it again?’, ‘I don’t remember,’ you know... And instead of spending 10 minutes in a busy workday, it’s easy to say, ‘I don’t have time for it today. I’ll do it another day’. We succeed in using it now and then, but it really requires a short and precise manual on how to do it [...]. It is not because they fear technology or anything... It’s just that... You tend to revert to old habits. Because that is easiest, I think. It requires persistence to say that this is what we want and this is what we do. I also experience, when we succeed, that we get feedback from next of kin where they say, ‘oh, it is so convenient that we can do it this way,’ ‘oh, it is so nice,’ and ‘we can see and hear that it works really well.’ I hope this kind of positive feedback can boost the implementation and get the laggards moving”, and that: “There has not been much resistance. Everyone can see that it makes sense in certain situations. But the thing is... To ensure that everyone maintains and uses it in these situations, and not take the line of least resistance, and then do what they normally do”. Unlike the other two units, there was no formal or informal follow-up and support from the trainers after the initial training course. Instead, they helped each other and used a short manual describing the process. According to the head nurse, “they are good at helping each other. Some remember better, some just used it, and for some it’s a long time since they used it. So, they use each other.” Initially, a secretary was formally assigned to be the unit’s superuser. However, after some time, a nurse “with a flair for technology” came back from sick leave and informally took over as the unit’s superuser. Three months after the initial training, the unit had held ten multidisciplinary meetings on video with the next of kin. The unit experienced that they “get to clarify the next steps faster, making the hospital stay shorter.” However, according to the head nurse, they “do not look at it as a financial saving, but as a quality boost when communicating with patients, next of kin and other collaborative actors.” Even though the objective of the video consultations was to strengthen the cross-sectoral collaboration, it ended up strengthening the involvement of next of kin as they “want to use it where it makes sense, and where it can benefit.”
Summary:
The nurses at the neonatal unit expressed that they acquired the needed skills to use video consultations with patients and families. However, their willingness to take responsibility for using video consultations depended on being able to decide whether a video consultation would be sufficient to satisfy their responsibility to the patients. The cardiology unit staff needed personal and communication skills and training in monitoring a patient behind a screen to use video consultations with patients. However, they were willing to take responsibility for using video consultations with peers (once a week), where patient soundness was not contested, and the same personal and communication skills were not needed. According to the neurology unit head nurse, the staff acquired the skills needed to use video consultations to communicate with the next of kin. As the patient was at the hospital, the patient's soundness was not contested. Instead, the patient soundness might have been increased as the hospital admission became more coherent by including the next of kin through video consultations. However, the neurology unit struggled to routinize video consultations and to change existing workflows as they experienced video consultations as being more time-consuming, even though they had the potential to make a hospital stay shorter. Next, we present the mechanisms and contextual factors that generated the various outcomes.
Mechanism 1: Workplace Learning
Support on the spot. After the formal training course, the trainers offered informal support in the units whenever needed. The informal support appeared to be particularly successful in providing a feeling of safety among healthcare staff when using new technology. The need for informal support often occurred the first couple of times when healthcare professionals used the technology.
Continuous follow-up and focus. Formally scheduled follow-up meetings 30-60-90 and 180 days after the initial training, along with the spontaneously needs-based support, led to a continuous focus on getting the video consultations implemented and to a continuous focus on ensuring that healthcare professionals had the needed competencies to use the video consultations. If the necessary competencies were lacking, healthcare professionals were frequently encouraged to continue practicing (with support).
Establishing responsible roles. Responsible roles were either assigned formally or taken informally. If assigned formally, the roles were given to either willing and technology-interested healthcare professionals or more “senior” staff with other pressing tasks or other areas of responsibility. If the last happened and no one took responsibility, some health care professionals took an informal responsible role. As such, there were formal or informal superusers to provide support. Available support among peers lowered the threshold of testing the new video consultation system.
Knowledge exchange across disciplines and sectors. The formal classroom training where staff across sectors were gathered led to a feeling of unity and knowledge exchange across disciplines and sectors concerning implementation challenges. However, formally scheduled video consultations with the municipality were not always coherent with the unpredictable workflows at the hospital.
Summary Fig. 1 shows a realist analysis of the enabling and constraining factors on workplace learning. The implementation experience suggests that efforts of workplace learning were more likely to succeed when there was available staff (trainers and superusers) to provide support and to ensure a continuous focus on implementing and learning how to use video consultations in day-to-day practice. Moreover, gathering multidisciplinary and cross-sectoral staff in training sessions might lead to a common understanding of varying workflows, challenges, and opportunities.
Mechanism 2: Professional Judgment
Coherence with patient soundness. Healthcare professionals expressed that video consultations increased the coherence with patient soundness when the technology was well functioning with a clear image and adequate sound and when healthcare professionals could decide whether a consultation should be real-life or on video. For example, if the patient had a high-risk condition. On the contrary, if the person on the other end of the video consultation was a peer or next of kin, the patient's soundness was not contested the same way.
Staff takes responsibility. The staff takes an informal responsibility to use video consultations if they experience video consultations as being coherent with patient soundness and their professional knowledge, and vice versa. The staff takes less informal responsibility if they experience large clinical and administrative workloads.
Responsiveness to professional knowledge and skills. Units with managers responsive to health care professionals' concerns regarding patient soundness were more likely to adjust the video consultations to the existing workflows and routines. Units with managers who were unresponsive, goal-oriented, and technology-pushing managers were more likely to increase resistance among healthcare professionals. The resistance led to video consultations not being used because they were not adapted to existing workflows and were not experienced as being coherent with patient soundness.
Summary. The realist analysis of approaches to adjusting the video consultations to workflows and routines (see Fig. 2) and not adjusting workflows and routines to the technology suggests that these efforts were more likely to be effective when video consultations were experienced as being coherent with patient soundness. If that were the case, healthcare professionals would take responsibility for using video consultations. However, unit managers had to be responsive to and trust healthcare professionals’ concerns and decisions regarding the patients to achieve that.